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HomeMy WebLinkAbout020-1333-50-000 l ST. CROIX COUNTY ZONING DEPARTMENT r AS BUILT SANITARY REPORT Owner A A A M I Property Address `7 ySf "--/ I rk, F, 0 k D. City /State H U - N 0✓ i Legal Description: Lot I S' Block Subdivision/CSM # :, '/a &LkZ t /4, Sec. 32 , T 11 N -R 1 (9, Town of (-1 y ' D So PIN # G) Z(f - TIC TAN -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer VJJ C - I L f' Size ST/Pd � Setback from: House Z Well /4 P/L / S Pump manufacturer --- Model Alarm location -- (HOLDING TANKS ONLY) Setbacks: Service road - -- Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: L � }� Width Length 7 ' Number of Trenches Setback from: House -Z Well ' P/�L Ta Vent to fresh air intake ELEVATIONS r Description of benchmark > l� r1 � / ' ' � /Z Elevation ?3' 2® ' Description of alternate benchmark - r 0P f ! 16C k N U � T ! o(+ ! S', eg Elevation 2. � Building Sewer It �� ST/HT Inlet . 5 : q 41 ST Outlet �O � 1 q 414 PC Inlet ` PC Bottom Header/Manifold 1 10 3 Top of ST/PC Manhole Cover `7� Z 2- / ?i fG 7z Distribution Lines ( ) I �5Z `� 5 O 1 2, ( ) Bottom of System Final Grade Date of installation e //Permit number 2 State plan number Plumber's signature c License number SD 3 Im Date /V /1 Inspector L li . Complete plot plan is l r 1 NOTICE: Please P rovide the following: • A plan view sketch showing everything within 100 feet of the system. Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW No R ,E 'w -- P1 /Y1f-To R LE VEL- ' t 514 a •T, AL !o� INDICATE NORTH ARROW I I Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Y Safety and Buildings Division Count ST . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) SanitaryP fa% lg.: Personal information you provice may be used for secondary purposes [Privacy La s.15.04 (1)(m)]. M Z l�lcler'sglaq�: [k kRIIage ❑ Town of: State Plan ID No.: — 7 CST BM AA11 Insp. BM Elev.: BM Description: GS Parcel TaxANi 1333- 50-000 7-- .2-4 , 19 . 1 a ss TANK INFORMATION ELEVATION DATA A9800524 TYPE MANUFACTURER CAPACITY STATION " B S S HI FS ELEV. Septic Benchmark 'l �f 3 .2 0 Dosing , 8 7•,36- I QO.2 Aeration Bldg. Sewer T -a•, / Holding St /Ht Inlet q. -7 9 ,qfl TANK SETBACK INFORMATION St /Ht Outlet TANK TO P/ L WELL BLDG. Airi to ntake ROAD Air I Septic I0 t �(O �� r —� NA Dosing A Header / Man. L q 3 Aeration t Dist. Pipe N 7o- 2V - 3Y L .( Holding Bot. System L / .:ot ?Z ] PUMP / SIPHON INFORMATION Final Grade Man urer Demand N�IGw•�K 6�3 �p. Z Model Number GPM CZ rc svS TDH Lift Fri TDH Ft ss ead ForceQvfLength Dia. Dist. To we SOIL AB PTION SYSTEM 3` REN H width t Len th No Of renches PIT No. Of Pits Insi Dia. Liquid Depth IM 3 X DIMENSION SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING M u rer, Std INFORMATION Type of r I � i CHAMBER �� del Number System: C�7"► 3g OR UNIT 1F1� — DISTRIBUTION SYSTEM Header/ Mani old ac Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length r ia. Length Dia. Spacing SOIL 8VE x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 27.29 .,19, n SE,NW 748 W L� FREp RD— BADLANDS PRAIRIE LOT 15 eJ �l ad uslAz Plan revision required? ❑ Yes No Use other side for additional information. I+ vix-Z, ( 2 x SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. Safety and Buildings Division SANITARY PERMIT APPLICATION ICATION 2 01 W. Washington Avenue P O Box 7302 Department of Commerce In accord with ILHR 83.05, Wis. Adm -Code Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County �° than 8 v2 x 11 inches in size. Jf Cf 0/h • See reverse side for instructions for completing this application State Sanitary Permit Number 361 q rP a-(o-p Personal information you provide may be used for secondary Qu s ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. 71 $ V% - A�d 1 ff :'— f. rid State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N `— Property Owner Na ropert Location . (_ S i 1!a Iva, 5 Z 7 T 7 , N, R E (o Property Own is Mailing Address Lot Number Block Number - /, --- City State ® Zip Code Phone Number Subdivision Name or CSM Numb r o QS 1. TYP E ILD NG: (check one) ❑ State Owned ❑ It Nearest Road o Public 1 or 2 Family Dwelling - No. of bedrooms o Tax Number(s) wn of U N t o" /G ©, Parcel Q 111. BUILDING SE: (If building type is public, check all that apply) p�,�. 1 ❑ Apartment / Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility'/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. New 2 ❑ Replacement 3. E] Replacement of 4. E] Reconnection of 5. ❑ Repair of an - _____System ________S� stem _____________Tank Only______________ ExistinQSystem --------- ExlstmgSystem B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) 61.0 Y� r� �rf�� Non Pressurized Distribution Pressurized Distribution 5 Expe men al Other 11 []Seepage Bed 21 []Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ]Seepage Pit i L7jLskTa Z 43 ❑ Vault Privy 14 ❑ System -In -Fill " o l" VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. Syste Elev. 7. Final Grade CC) Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) 4 12 I T 8 Ele�yaiion I Z C 1 ( , $ °°.. (� S © Feet q 0, 5 Feet VII. TANK Cal paat Site gallons Total # of Prefab s Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existin structed Tanks Tanks eptic Tan Holding Tank e ( El 0 1:1 11 Li ump Tank !Siphon Chamber ❑ E1 I El Q E VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: Stamps MPlMPRSW No.: Business Phone Number: mlk�le t` L. - �iCS Q (o P mber's Add ess (Street, City, State, Zip Code): 4U t474r, 76 jeZo 47e IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuin gent Signature (No Stamps) Approved [:]Owner Given Initial 0 VC/, �urcnargeFee> /'Q� I xp",gm Adverse Determination 7 X. CONDITIONS OF APPROVAL / REASONS FO DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to county. One copy To: Safety & Buildings Division, Owner. Plumber . B# T o "1 kLLf'VtlFD ki), UJ (i r-'!R)F 0 10 7A 114 T R gott c Ol t FAcH r4 A ST r3 E Ric DQ� L EX L I T jlLEVE rSs E> g, -5 If 7 13' - --- L-L-T Tli Z- pvc ZC 4H �;e r,4 c E E a m � w X (6 Q � N co L M u C to r _ Cv _0 to C +� O X r 0� U) O O O o IV) ��L N N L2 c0 d cn - C cd S C ® C O O N O N H — N `•` j U _ + C C C > p Ct p • 2 a) '- -0 ' � _ X _ p ;T y m_ N O C U .0 -p ?— \�► O t E O y N N � C > Q O O j r cri N> 0 0 O J co u- E O = U C3 • • • • co �t > 0 ® w' vv co co AL N MM v m &i N u > t �s U O t7 �J m 0 4 `o `O + ^` to wto W O O ( L $# W C _ LL ` I Loo a$ Too C `) C 7 � J �� Wisconsin- Department of Industry SOIL AND SITE EVALUATION 1 of 3 Labor and Human Relations Page Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please print all i rmAdo", Re awed by Date Personal information you provide may be used for secondary pu eS (Privacy Law, 13:44Nj(� ' /p /�� Cl Property Owner �- Pro' rty ovation Richard Stout ,f �'% ' Govt. fot. E 1/4 NW 1 / 4, S 2 7 T 2 9 �N 9 XR(or) W Property Owner's Mailing Address - „ I �t # a- ck# Subd. Name or CSM# 1353 Awatukee Trail +? 'I Badlands Prairie City State Zip Code P umber 'COUNTY `: El Village k] Town Nearest Road Hudson WI 54016 (7 x. 5�tatl�Qcfi son IState Hwy 12 77 7 ® New Construction Use: Ej Residential/ Number o ` Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 6 0 0 g pd Recommended design loading rate - 7 bed, gpd /ft 8 trench, gpd /ft Absorption area required 858 bed, ft 750 trench, ft 2 Maximum design loading rate • 7 bed, gpd /ft • 8 _trench, gpd /ft Recommended infiltration surface elevation(s r P n r h 1 — 9 S 0 trench 2 - 91 ' Mas referred to site plan benchmark) Additional design /site considerations Parent material Glacial depo sit Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system ®S ❑ U &I S ❑ U E� S ❑ U [ 1 S ❑ U ❑ S )a U ❑ S �4 U SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Mottles Structure GPD /ft 9 Texture Consistence Boundary Roots in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 1 1 -12 7.5yr2.5/1 none L 2mbk mfr cs if .5 .6 2 12 -4 10yr4/4 none is ogr mvfr gs if .7 .8 Ground 3 0 -9 10yr4/6 none ms osg ml gs -- .7 .8 elev. 9 6 - -2 - 0 t. Depth to limiting factor 9 0 in. Remarks: Boring # 1 0 -12 7.5 r2.5/1 none L 2mbk nf 2 2 12 -32 10 r4 4 none it 3 32 -89 10yr4/6 none s DSg nl Cs - .7 .8 Ground elev. 92 Depth to limiting factor 8 9 in. Remarks: CST Name (Please Print) Signature Telephone No. Of Address Date CST Number SOIL DESCRIPTION REPORT PROPER #Y OWNER R chard St out _ Page 2 of 3 PARCEL I.D.# i Boring # Horizon Depth Dominant Color Mottles Structure 2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench 3 1 0 -8 1Oyr4/4 none Ls Dgr nvf r JS 1f .7 A 2 8 -90 10yr4/6 none s Dsg n1 JS -- .7 A Ground elev. 9 Depth to limiting ; factor Remarks: Boring # 4 2 12-10 10 r4/4 none is o r mvfr gs 1f .7 -.8 3 40-E9 10yr4/6 none ms osg ml gs - .7 '.8 Ground elev. 9 Depth to limiting factor 8 g in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # 1 0-14 7.5 r2.5 1 none L 2mbk mfr Cs if 2 14- 1 10yr3/4 none sil 2mabk mfi Cs 1f .5'.6 5 , 3 41- 0 10yr4/E none ms osg ml Cs -- .7,.8 Ground elev. 9 2 -2 ff Depth to limiting factor 9 0 in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBDW -8330 (R. 08/95) - �.6T �s I 2 Tre.� � � s �v,'�h /'s �✓ � .ems 0 � n 0 y . � ��' �risY✓f a i f I r ST CROIY COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer S A111 M <C L'Fil -- Mailing Address 1.. O)( Property Address ` t L F KE Q (Verification required from Planning Department for new construction) --- City /State 4 UD2So 14 tV l Parcel Identification Number 0 ZC) — 33 LEGAL DESCRIPTION Property Location ' /a, %a, Sec. 7 , T � r N -R 17 Town of 'Subdivision I-A N b 64 4z 1 i— , Lot # I r Certified Survey Map # 40 1 0 , Volume (° ,Page # Warranty Deed # 56 3 y 8 -S , Volume / Z S (a , Page # (3 / Spec house yes ❑ no Lot lines identifiable yes ❑ no SYSTEM MAINTENANCE Impbaper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit io St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restrictedplumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards.. set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to St. Croix County Zoning Office within 30 da-vs of the three year expiration date. ATURE F Aki ICANT DATE =:':y nWNER CERTIFICATION certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of op�iefy described above, by virtue of a warranty deed recorded in Register of Deeds Office. �ATFl __. <.t4T DATE * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** *# Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed - ,] ` SATE BAR OF WISCONSIN FORM l - 1982 WARRANTY DEED s W4 �,1 f 1 •J x This Deed, made between Richard O. Stout Grantor, ' A UG ig9 t 7 ' and Sam R. Miller _ f Grantee, Witnesseth, That the said Grantor, for a valuable cons n - - L conveys to Grantee the following described real estate in St. Cr oix THIS SPACE RESERVED F q RECORDING DATA County, State of Wisconsin: NAME AND RETURN ADDRESS Lot 15, Plat of Badlands Prairie, Town of Hudson, St. Croix County, Wisconsin. a PARCEL IDENTIFICATION NUMBER s' .4 " TRA �i This is not homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging, And Richard O Stout warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except i easements, restrictions and rights -of -way of record, if any, and will warrant and defend the same. Dated this 4th day of _ August ,19 9 .� 1s -1G14� & As . (SEAL) _ (SEAL) Ric - Ird O. Stout ' `. (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMEN f Signature(s) State of Wisconsin, ss '> St. Croix County authenticated this day of _ 19_ Personally came before me this 4th day of August , 19 , dRabove named { Richard O. Stout TITLE: MEMBER STATE BAR OF WISCONSIN _ _ - � (If not, 3t authorized by §706.06, Wis. Stats) to me known to be the person _ _ wio e.ecwt:d the foregoing instru nt a ac ledge the me. THIS INSTRUMENT WAS DRAFTED BY Janet P. Stout — 1353 Awatu3cee `Pr : -- _ -- Hud son, Wl . - 5 4016 — -- Notary PtlbGc, C .lq _ �w — ___ - -^ County, Wis (Sllnatr.ns may Ix authcnucated or ackno�cledged Both a., not Sly :on si— Is pe�rm df not, s+.uc cxpiratmn date • \.^..>ol txr.,m adni�ig n am Gaon. h,ru'd n. ,�d. , r�ai b. !:+ - .' „=� STATE RkA Of wbCtT \SIX 'NSC:nsr aga:9a ^ -� nc N 041 741'• E 421.46' Ab I C m O I co N lti j \ mss. ' Z �� - i - -'`� c`"•,) .\ .t u1 C43 �C3 DO 4 5 1 N 05 ?6'05.. 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